Tuesday, May 27, 2014

Polycystic Ovarian Syndrome: A Silent Misery

From The Daily Star:

A young girl, 15 years old, struggles with acne ever since her periods started. And not too long ago, she noticed dark thick facial hair around her chin and over her cheeks, something that can be socially crippling in school. No amount of waxing, threading and bleaching helps and this 15-year-old is miserable.

A couple has been trying to conceive for nine months with no positive result. In a country with an over-population problem and a serious lack of understanding of infertility and sexual health, there are usually misunderstandings on the varied number of reasons as to why a couple may not be able to conceive. There are grumbling in-laws, a lot of finger-pointing and blaming, usually the women, which does little to help the situation.

A 27-year-old woman has very irregular periods. She has gained a lot of weight over a year or two. She feels bloated and uncomfortable with friends and family being rather insensitive to her recent weight gains. Not having periods regularly also makes her scared about her future, especially when she thinks about marriage and children.

A 22-year-old woman feels extreme pain in her lower abdomen. When she is rushed to hospital, the doctors suspect appendicitis but ultrasounds show that her appendix is fine. However, because she has a sexually active relationship with her boyfriend and does not want her family or even her doctor to find out, she provides limited information on her symptoms which leads to inconclusive diagnosis.

What do these women have in common? They have Polycystic Ovarian Syndrome.

For reasons that are not well understood, in PCOS the hormones get out of balance. One hormone change triggers another, which changes another. For example:

The sex hormones get out of balance. Normally, the ovaries make a tiny amount of male sex hormones (androgens). In PCOS, they start making slightly more androgens. This may cause you to stop ovulating, get acne, and grow extra facial and body hair.

The body may have a problem using insulin, called insulin resistance. When the body doesn't use insulin well, blood sugar levels go up. Over time, this increases your chance of getting diabetes.

The cause of PCOS is not fully understood, but genetics may be a factor. PCOS seems to run in families, so your chance of having it is higher if other women in your family have it or have irregular periods or diabetes. PCOS can be passed down from either your mother's or father's side.

For more information or to schedule an ultrasound, please call: (718)925-6277.

Monday, May 19, 2014

The New Pregnancy Test

When I began my career in medicine, pregnancy tests were relatively insensitive. You had to wait until about 4-6 weeks after the last menstrual period before the results could be regarded as reliable. Real time ultrasounds was a gleam in a few researchers' eyes. Most women with a tubal pregnancy had the diagnosis made when they arrived in the emergency room with serious intra-abdominal bleeding. The confirmative diagnostic test of choice was a culdocentesis - the insertion of a long needle into the abdominal cavity through the vagina. Aspiration of non-clotting blood was considered diagnostic of internal bleeding. An unruptured ectopic pregnancy was considered a reportable case. The treatment was removal of the affected tube at laparotomy.

All that has changed. Today, thanks to Dr. Yalow's development of radioimmunoassay, pregnancy can be diagnosed sometimes before a period is missed. Transvaginal ultrasaound can diagnose an ectopic pregnancy often prior to the onset of significant symptoms. Surgery is done, not via large incisions, but via small laparoscopes - the so-called "bandaid surgery." And often, tubal pregnancy is treated medically or even followed expectantly. These have been truly remarkable developments.

In fact, the new pregnancy test may well be the vaginal sonogram. The new protocol for a woman who is seeing her gynecologist for suspected early pregnancy to empty her bladder and save that specimen of urine for the lab. But today, the office doesn't run the urine test yet. Today, her gyn performs a vaginal sonogram. If pregnancy is seen, that's it - she's pregnant. Done! If a small embroy/fetus is seen, a measurement yields an estimated delivery date which is more accurate than that predicted by last period. Early diagnosis of twins can also be made. If a fetus is seen, so can the heartbeat be seen. Everyone is ahead of the game.

The flip side is if no evidence of pregnancy is found on the sonogram. Now, that urine test is crucial and should be run. Urine tests are far more reliable than they were in the 1960's and early 1970's. If the test is negative, pregnancy is doubtful. Conversely, if the test is positive, then blood should be taken right then and there to look for the level of pregnancy hormone - the Beta HCG. Further management would then depend on that level which could be available often in less than a day. An investigative work up which often took weeks can sometimes be compressed into a few days or less.

Of course, I am oversimplifying but the change in the investigation and treatment of suspected tubal pregnancy has been truly remarkable stuff.

For more information, or to schedule an ultrasound, call: (718) 925 - 6277.

Thursday, May 15, 2014

Lupus In Pregnancy - What Should I Know?

Continuing the lupus thread duing Lupus Awareness Month, let's look at lupus during pregnancy. First, you should know that having lupus does not preclude a successful pregnancy outcome. There are risks involved, however, for both mom and baby. The March of Dimes ists the following:

What problems can lupus cause during your pregnancy?

Lupus may increase the risk of these problems during pregnancy:

Lupus flares. You may experience flares during pregnancy or in the first few months after giving birth. If your lupus is in remission or under good control, you’re less likely to have flares.

Preeclampsia. This is a certain kind of high blood pressure that only pregnant women can get.

Premature birth. This is birth that happens too early, before 37 weeks of pregnancy.

Miscarriage. This is when a baby dies in the womb before 20 weeks of pregnancy.

Stillbirth. This is when a baby dies in the womb after 20 weeks of pregnancy.

If you’ve been in remission or had your condition under good control for at least 6 months before pregnancy, you’re less likely to have complications. Talk with your health care provider before getting pregnant about the safest time for pregnancy.

What problems can lupus cause in your baby?

Most babies of mothers with lupus are healthy. However, some babies may face health risks, like:

Premature birth. About 3 in 10 babies (30 percent) of mothers with lupus are born prematurely. Premature babies may need to stay in the hospital longer or have more health problems than babies born full term (39 to 41 weeks of pregnancy).

Neonatal lupus. About 3 in 100 babies (3 percent) are born with this temporary form of lupus. This condition causes a rash and blood problems but usually clear up by 6 months of age. However, up to half of these babies have a heart problem called heart block. This is a condition that causes a slow heartbeat. Heart block is often permanent. Some babies need a pacemaker to help make their heart beat regularly.

As you would expect, pregnancy for a lupus patient is hardly a walk in the park. However, there is ample evidence that remission in disease activity optimizes a woman's chances for a successful outcome.

During pregnancy, expect to see two consultants on a regular basis - the Maternal Fetal Subspecialist and your Rheumatologist. Expect to have many tests and frequent visits. Do keep your appointments to give yourself and your baby the best possible odds. And above all else, hang in there. You can emerge with a healthy, happy baby.

For more information or to schedule an appointment for an ultrasound, call: (718-925-6277)

Monday, May 12, 2014

Cervical Cancer Rates Rising in Seniors

Recent changes in pap smear frequency suggest that pap smears may no longer be necessary for women 65 years of age or older. There are a few big IF's:

Those with three consecutive negative Pap tests in the last 10 years, or two consecutive negative Pap tests combined with negative HPV tests in the last 10 years, with the most recent test performed within the past 5 years.

Now comes this news.

Previous studies determined that the rate of cervical cancer was approximately 12 cases per 100,000 women in the U.S. The incidence of the disease peaks in women between 40 to 44 years, then tapers off. However, such estimates did not take into account women who had hysterectomies, and are therefore no longer at risk for developing cervical cancer. Once these women were factored out, the incidence of this type of cancer increased to 18.6 cases per 100,000 women. The rate steadily increased as women age, particularly in women between 65 and 69 years of age.

African-American women had a higher incidence of cervical cancer at nearly all ages compared to caucasian women, with the discrepancy becoming more pronounced at older ages.

The study’s lead author Anne F. Rositch, Ph.D., M.S.P.H., an assistant professor of epidemiology and public health at the University of Maryland School of Medicine and a researcher at the University of Maryland Marlene and Stewart Greenebaum Cancer Center, believes these findings are important when reevaluating the screening guidelines for cervical cancer in older women in the U.S. Appropriate interventions need to be initiated to lower the burden of cervical cancer in these women.

Will the abandonment of the annual pap snatch defeat from the jaws of victory in the fight against the cancer that killed Evita Peron? While we do not want to spend precious healthcare dollars on needless testing, we do not want to put women's lives at risk in the process. I would urge any woman to have these conversations with her doctor before choosing either to continue or to forgo pap smears. Choose wisely indeed.

For more information or to schedule an appointment for an ultrasound exam, call: (718)-925-6277.

Friday, May 9, 2014

Miscarriage - Can It Be Lupus?

May is Lupus Awareness Month. Lupus is an autoimmune disease in which the immune system attacks the body's own tissues, causing inflammation, swelling, pain, and damage. Lupus symptoms include fatigue, joint pain, fever, and a lupus rash. But sometimes, adverse pregnancy outcomes such as repeated miscarriage are the first sign of this disease.

Although an uncommon cause, risk of miscarriage is higher in patients with an autoimmune disease such as lupus.

If you've had two or more miscarriages and are unsure, you should ask about a diagnostic investigation. Your health as well as a successful pregnancy outcome may depend on it.

For more information, or to schedule an ultrasound, please call: (718) 925-6277.

Wednesday, May 7, 2014

Handle With Care

I'm sure everyone's seen the headlines trumpeting Powerball-sized verdicts in medical liability cases involving children born with severe neurological impairment. I mean it's common knowledge that these injuries are always caused by lack of oxygen during the birth process, right?

It turns out that in most cases, common knowledge is wrong.

From this week's New York Times:

... The truth is far more complex, according to an important new report by a committee of experts in obstetrics, pediatrics, neurology and fetal-maternal medicine. Many conditions that occur during or even before pregnancy can lead to neurological damage to full-term babies.

The document, called Neonatal Encephalopathy and Neurologic Outcome, updates a version published in 2003 that focused on oxygen deprivation, or asphyxia, around the time of birth. The new report, which highlights significant advances in diagnosis and treatment in the decade since, was published by the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics. Brain injuries affect about three in 1,000 babies born full-term in the United States, but only half of these cases are linked to oxygen deprivation during labor and delivery, according to the new report. And even in those instances, a problem that occurred long before birth might have exaggerated the effects of a reduced oxygen supply that would have not otherwise caused a lasting brain injury.

According to the 2003 report, fewer than 10 percent of children with cerebral palsy, the most severe such brain injury, showed signs of asphyxia at birth. Unless certain clear-cut symptoms are present then, brain abnormalities are probably not the result of a complication during labor or delivery, the new report states.

The other side of the coin is that because of the way these cases are handled and the monumental cost involved, not only monetary by the way, many folks feel they have little choice but to find a lawyer. Additionally, obstetricians' response has been predictable with C-Section rates amounting to about one in three births in an effort to avoid the courtroom.

Surely, there has to be a better way.

Tuesday, May 6, 2014

Autism and Labor Induction: ACOG Weighs In

In October, a study by Gregory et al using North Carolina birth records reported a possible association between labor induction or augmentation with an increased risk for autism. Because of the increased incidence of autism and the frequency of oxytocin use in labor, this study resulted in quite a bit of both media buzz and alarm. Many, including both the authors and one recovering obstetrician, commented on the problems with this study and urged caution in interpreting the study's findings.

In the May issue of the journal Obstetrics and Gynecology, the American Congress of Obstetricians and Gynecologists (ACOG) weigh in with a Committee Opinion also endorsed by the Society for Maternal-Fetal Medicine (SMFM.)

...Although the Gregory study suggested an association between ASD and labor induction or augmentation, the study design could not determine if such findings were truly a result of cause and effect. This was recognized by the authors, who noted that interpretation of their findings was limited by missing data regarding important potential confounders, the use of education as a proxy for socioeconomic status, and a lack of data regarding induction indications and methods. They concluded that the “results are not sufficient to suggest altering the standard of care regarding induction or augmentation…though additional research is warranted” (20).

Subsequent to its publication, the Gregory study has been criticized because of limitations in defining the exposure and the outcome of interest (21). Critics note that investigators did not know the specific individual or combination of agents that were used for labor induction or augmentation. The critics also note that the American Psychiatric Association reported an editorial error in the criteria listed for the diagnosis of pervasive developmental disorder not otherwise specified in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV); an error potentially leading to overdiagnosis during much of the time covered by the Gregory study (21).

The ACOG publication concludes:

Current evidence does not identify a causal relationship between labor induction or augmentation in general, or oxytocin labor induction specifically, and autism or ASD. Recognizing the limitations of available study design, conflicting data, and the potential consequences of limiting labor induction and augmentation, the Committee on Obstetric Practice recommends against a change in current guidance regarding counseling and indications for and methods of labor induction and augmentation.

Stay tuned.

Monday, May 5, 2014

Five Prenatal Tests Women Over 35 Should Consider

The other day, this piece on prenatal diagnosis appeared in my inbox.

While the CDC reports almost 15 percent of all U.S. babies -- or 1 in 7 -- were born in 2010 to women 35 and over, much tongue-clucking persists about women waiting to have a baby at "advanced maternal age." The reason may stem from data that shows certain risks (such as having a baby with Down syndrome) can increase with age. However, many women are happily embracing motherhood later on.

That said, certain tests and procedures are often recommended for women over 35. Here, 5 prenatal protocols these expectant moms may want to consider and what "older" moms who've been through them say about their experience.

The article goes on to list the 5 tests -

1. amniocentesis
2. nuchal translucency screening
3. Noninvasive Prenatal Testing (NIPT)
4. chorionic villus sampling (CVS)
5. midtrimester ultrasound

While this is a useful article as it provides background prep for moms to be for conversatons with their OB's and midwives, it lumps screening tests together with diagnostic tests, losing some perspective.

So let's look at this issue in another way. Put simply, a screening test is one which is relatively noninvasive, provides odds and stratifies risk, but does not tell you yes or no. A diagnostic test is often more invasive with real risks and answers specific questions. For example, a screening test for Down's Syndrome would yield a risk in the form of odds. A diagnostic test for Down's would yield a definitive result.

Amniocentesis and CVS are diagnostic tests. While they usually provide definitive results (with a few, thankfully rare exceptions,) nuchal translucency, NIPT and midtrimester ultrasound are more screening tests.

Also, some of these are performed in the first trimester, others in the second. NIPT, nuchal scan, and CVS are first trimester tests. The advantage here is that the earlier this hurdle is jumped, the less stressful the longer remainder of the pregnancy is.

Finally, a few words about ultrasound. IMHO, both first and second trimester ultrasound will remain standard in prenatal care, similar to early newborn physicals and the more comprehensive baby visit a month or so after birth. Many abnormalities and syndromes do not have a basis in chromosome complement, thus a test designed to screen for a chromosome issue such as Down's would not find cases of spina bifida, for example.

Prenatal ultrasound is also more than just looking at structure. It keeps pregnancy real in a tangible way for not only mom but also for dad.

For more information, or to schedule an ultrasound, please call: (718) 925-6277.

Thursday, May 1, 2014

Nature Or Nurture

We all have heard the saying, "You are what you eat." Now there may be evidence that statement may apply to developing fetuses too. Research shows that a mother's diet around the time of conception can permanently influence her baby's DNA.

... Scientists followed 84 pregnant women who conceived at the peak of the rainy season, and about the same number who conceived at the peak of the dry season.

Nutrient levels were measured in blood samples taken from the women; while the DNA of their babies was analysed two to eight months after birth.

Lead scientist Dr Branwen Hennig, from the London School of Hygiene & Tropical Medicine, said it was the first demonstration in humans that a mother's nutrition at the time of conception can change how her child's genes will be interpreted for life.

She told BBC News: "Our results have shown that maternal nutrition pre-conception and in early pregnancy is important and may have implications for health outcomes of the next generation.

"Women should have a well-balanced food diet prior to conception and during pregnancy."

What's going on here? Epigenetics, functionally relevant changes to the genome that do not involve a change in the nucleotide sequence.

...One such modification involves attaching chemicals called methyl groups to DNA.

Infants from rainy season conceptions had consistently higher rates of methylation in all six genes studied, the researchers found.

These were linked to various levels of nutrients in the mother's blood.

But it is not yet known what the genes do, and what effect the process might have.

The study, published in Nature Communications, demonstrates that a mother's diet can have epigenetic effects.

So which is it - Nature or Nurture? The answer may truly be both.

For more information, or to schedule an ultrasound, please call: (718) 925-6277